Sunday, June 17, 2007

Home Health Aides: Who Takes Care of Them?

A basic rule of thumb is that supply and demand sets prices. If there's a large supply of something, say, plasma TVs and less demand, prices for plasma TVs go down (check out any electronics store). Conversely, if there's a huge demand for something and smaller supply (gasoline), prices go up. Supply and demand rules cover salaries as well as widgets. Salaries are driven up when the labor market tightens. Salaries go down when there are too many applicants for too few slots.

It seems when poor, minority women are involved, the rules of supply and demand fly out the window. As the population ages, demand for home health aides is exploding. There are an estimated 250,000 home health aides currently employed, mostly by private, for-profit agencies that charge their clients around $25 per hour (or more). The home health aides that work for these agencies earn a median hourly wage of $8.81, generally without benefits like paid vacations and health insurance, Bureau of Labor Statistics, Department of Labor, Occupational Outlook Handbook, 2006-07 Edition

Some backstory: Overall employment of home health aides is the fastest growing occupation as a result of both growing demand for home services for an aging population and efforts to contain costs by moving patients out of hospitals and nusing care facilities as quickly as possible.

Recently the Supreme Court refused to do anything about a 1975 Labor Department regulation that excluded home health aides from basic labor protections like the minimum wage and time-and-a-half for overtime. Evelyn Coke, 73 and in poor health herself, made her argument and there was no dispute about the facts.

Employed for 20 years by the agency Long Island Care at Home, she was often on duty for more than 8 hours a day, including many 24-hour stretches in the homes of elderly people she was assigned to care for. Care included such things as: lifting an elderly person out of bed, taking him to the bath, bathing him, changing his diapers, going shopping and cooking for him, making sure he takes his medicine and turning him over in bed if he's immobilized, and many, many other tasks. Because people are living so long due to better medical care and nutrition, many more get Alzheimer's disease and other dementias, so they require all the care I mentioned before and then some. Alzheimer's patients can be very unpredictable, hostile to the point of physical violence, and often require close 24-hour a day monitoring.

All 9 Supreme Court Justices rejected Ms. Coke's argument the Congress intended to include home health employees in the labor law and to exclude only certain domestic workers, like baby sitters and companions from the elderly who are paid by the families they work for.

The Supremes are strict when the mood strikes them. They ruled that Congress authorized the Labor Department to write the regulation on who was to be covered under the law and that the Labor Department properly did that. Justice Stephen Breyer wrote that, given those circumstances, deferring to the Department's rule "is what the law requires."

"Fair Labor Standards Amendments of 1974 exempted from the minimum wage and maximum hours rule of the Fair Labor Standards Act of 1938 (FLSA) persons "employed in domestic employment to provide companionship services for individuals...unable to care for themselves." 29 U.S.C. Sec.213(a)(15) Under a Labor Department regulation...the exemption includes those "companionship" workers "employed by other than the family or household using their services." 29 C.F.R. Sec.552.109(a)

The fact that the use of home health aides can cut costs flies in the face of powerful forces opposing reregulating home health aides, such as the Bush administration and the Bloomberg administration. They opposed Ms. Coke's claim to overtime pay by arguing that federal labor law protections for home health aide workers would drive up the cost of Medicaid and Medicare which cover many home health care bills.

As The New York Times wrote in their editorial, "Congress and the Caregivers" on 6/15/07, "Refusing to pay employees fairly for the word they do is not an acceptable way to keep costs down."

Monday, June 11, 2007

Promising Developments in Alzheimer's Research

A change of scenery from politics: There are signs of hope in the treatment of Alzheimer's disease. [I work at a non-profit that deals with Alzheimer's disease.] As you may or may not know, Alzheimer's is a dreadful disease which robs the afflicted of their minds and eventually their lives. Though we know that many people over 85 will get Alzheimer's disease, we don't know the cause or have a treatment for the disease.

I will share what little I know about the disease. It causes memory loss, physical loss, and loss of reasoning and judgment. Through autopsies of the brains of people with Alzheimer's, we see plaque and tangles in their brains rather than neurons. Their brains have shrunk to a much smaller size. It's as though the disease consumes the brain.

There are different explanations for the tangles and plaque. One source blames something called an amyloid protein for AD. Amyloid is one of various complex proteins that occur in a number of diseases. Scientists heatedly disagree as to whether amyloid causes Alzheimer's or is simply a sign of the disease apart from its source. Many proponents of the amyloid-as-cause theory believe that the depositing of beta-amyloid protein kills neurons and thus causes Alzheimer's. Others believe that the accumulation of the protein tau is a defining feature of Alzheimer's. Tau lives in the cell and holds the cellular structure in shape. According to this theory , tau collapses on itself and becomes tangled. Meanwhile, the amyloid protein, which in a healthy brain is usually a clear liquid, gets gooey and forms plaque between cells, interfering with neural communication. The tau tangles and the amyloid plaque cause brain cell death.

The plaque and tangles start in the hippocampus, which is the central brain area that takes short term memory and converts it to long-term memory. By the time an AD sufferer dies, 50% of the hippocampus is destroyed.

You may well ask, if scientists know that amyloid and tau cause problems in the brain, why can't we stop them? The problem is, we're not sure that's what's causing the Alzheimer's. Even the diagnosis of AD is subjective. You go to an Alzheimer's Research Center and have physical, neurological, cognitive functioning and memory tests. In NYC these centers are located at Mt. Sinai, NYU and Columbia hospitals.

Often people worry that they have Alzheimer's if they forget where they put their keys or forget a name attached to a familiar face. But there are benchmarks that are specific to Alzheimer's. In the early stage, the person starts to lose his or her executive functioning (not being able to manage a checkbook; hard time going grocery shopping; can't come up with a plan and implement it to solve problems; Forgets to pay bills; Starts losing ability to communicate ("searching for words"); Forgets appointments and doesn't recall he or she has one; Loses initiative to organize activity; Grooming changes (not so meticulous).

In the middle stage, the person is: Asking the same question over and over; disinhibited (forgetting social niceties and says what they're thinking without interior censor; Reason and judgment severely impaired; Communication losses continue; Very frustrated; May hallucinate and become paranoid; Can remember more long-term memories as opposed to short-term memories.

In the late stage, all language is lost (maybe retains 1-3 words). Can utter sounds and syllables. Loses ability to walk. Incontinent. Can't feed themselves. Needs 24-hour, around-the-clock care.

It is a sobering list, especially disquieting in light of our ignorance about the cause and treatment for the disease, let alone a cure. There are several FDA-approved drugs on the market that treat the symptoms of the disease. Aricept and Excelon keep acetycoline from being destroyed. Acetylcholine is a neurotransmitter found in the central nervous system. It is a chemical that allows neurons to communicate with each other. Acetylcholine's role in learning and memory is unclear but Deutsch in 1970 believed that because most of the acetylcholine in the neocortex originates in the basal forebrain, that cholingeric synapses themselves were the site for memory storage. These drugs also replace the depleted levels of acetylcholine. Rasidine stimulates brain cells to produce more acetylcholine (it inhibits a naturally-occurring anti-acetylcholine chemical). Other drugs are used to enhance the brain's cholingeric system. The drug Namenda acts like glutamate, another neurotransmitter like acetylcholine. These drugs do not reverse disfunctionality, or even arrest progressive deterioration, but they do extend some functionality over a short time.

However, there are discoveries all the time about possible cures and treatments for Alzheimer's. We mustn't give up hope. I mean, it's true that Alzheimer's is a progressive, degenerative and irreversible neurological disease with no cure, but there are hopeful signs on the horizon. There was an article in the 6/10/07 New York Times on the first page of the Business Section, headlined, "Taking on Alzheimer's". Wyeth Laboratories used a vaccine to attack the amyloid plaque in the brain. (It did have mixed results in human testing, but some patients responded very well.) To prevent any more side effects, Wyeth decided against continuing to use a vaccine to induce natural antibodies in the participant. They developed passive immunization, infusing participants with the antibody product bapineuzumab.

At Wyeth's research laboratory, scientists tested this product on mice that had been genetically altered to induce Alzheimer's. Normal mice could remember where a raised platform was in a pool after they found it once, but the genetically altered mice couldn't. They kept swimming around in circles, unable to find dry ground. After they were treated with bapineuzumab, they were able to remember better where the platform was, and in scan pictures their brains improved. They had less plaque and tangles than they did before they were given bapineuzumab.

In a more recent article in the 6/11/07 New York Times, patients in a drug trial treated with the antihistamine Dimebon did better than those receiving a placebo on all five measures of cognition and behavior. As with the other drugs mentioned, Dimebon treats the symptoms, not the underlying disease.

The results of the drug trial after 12 months showed that patients on the drug were better or the same as at the start of the trial. This suggests that the drug improves functionality, not merely slowing decline.

People affected by Alzheimer's disease, whether they are caregivers, persons with Alzheimer's or in the family of someone with Alzheimer's, are organizing and becoming politically active, increasingly advocating for more funds for the disease. As the population ages and more become ill, research on Alzheimer's is more urgent than ever.

Saturday, June 9, 2007

We Have Met the Enemy, and He is Us

We truly live in Orwellian times.

Orwell was heavily influenced by the tactics of Joseph Stalin when he wrote 1984. During the late 1930s, Stalin orchestrated the Great Purge, the name given to campaigns of political repression and persecution in the Soviet Union. It was a period marked by omnipresent police surveillance, widespread suspicion of "saboteurs", imprisonment and killings. During the Great Purge, there were the Moscow trials, a series of trials of political opponents of Joseph Stalin. Today the Moscow trials are universally acknowledged as "show" trials, in which the verdicts were predetermined using extorted confessions. The defendants were accused of conspiring with the Western powers to assassinate Stalin and other Soviet leaders, dismember the Soviet Union and restore capitalism.

In 1984, the party with its figurehead, Big Brother, holds absolute power. The physical descriptions of Big Brother mirror that of Joseph Stalin with his omnipresent pictures everywhere. The party's slogans are, "War is Peace, Freedom is Slavery, and Ignorance is Strength". The meanings of words are turned against themselves. Bush constantly asserts that America represents the beacon of democracy and freedom in the world, and that our goal in the Mideast was to allow democracy and freedom to flourish. As Bush mouths these words, turned hollow and meaningless by his actions and the events that followed, America adopts totalitarian tactics similar to those under Stalin.

We talk about democracy and freedom while our government engages in the darkest sort of behavior. We emulate our Cold War adversary, the Soviet Union, in how we mete out justice.

In The New York Times article of 6/3/07, "Soviet-style "Torture" Becomes "Interrogation", the reason for the striking similarities between America's recently adopted form of questioning prisoners and the Soviet Union's is starkly etched. In 2002, the C.I.A. and the Pentagon felt their usual tactics of interrogation were inadequate for suspected terrorists. They turned to a military training program called S.E.R.E., which stands for Survival, Evasion, Resistance and Escape. The purpose of the S.E.R.E. program was to expose soldiers at high risk of capture to Soviet-style interrogation techniques, including:

  • Disrupted sleep
  • Exposure to extreme hot and cold
  • Hours in uncomfortable stress positions
  • Waterboarding, where a prisoner's face is covered with cloth and water is poured from above to create a feeling of suffocation

Some of these techniques have been used on prisoners at Guantanamo Bay, Afghanistan, Iraq and at the C.I.A.'s overseas jails for high-level operatives of al-Qaeda.

When S.E.R.E. trainers learned that the C.I.A. and the American military adopted the Soviet-style methods used in the S.E.R.E. program against captured al-Qaeda members, they were aghast. Charles A. Morgan III, a Yale psychiatrist who has woriked closely with S.E.R.E. trainers for a decade, asked, "How did something used as an example of what an unethical government would do become something we do?"

As discussed in the Times piece, a 1956 article, "Communist Interrogation" published in the Archives of Neurology and Psychiatry shows that methods embraced after 2001 were once considered torture that would produce false information. In other words, these Soviet-style techniques were ineffective in yielding usable information.

The 1956 report describes basic Soviet N.K.V.D. (later K.G.B.) methods:

  • Isolation in a small cell
  • Constant light
  • Sleep deprivation
  • Cold or hot
  • Reduced food rations

The effects of these methods produced disturbances of mood, attitude and behavior in nearly all the prisoners.

Other techniques were not considered "torture" by either the interrogators or the prisoners even though they produced excruciating pain, such as requiring the prisoner to stand throughout the interrogation or maintain some other physical position until it becomes painful.

American and Soviet approaches to interrogation are eerily similar. In the Soviet system, closed trials and military tribunals were standard. Just as in American law, military tribunals were not public courts, they were held in secret, with only the interrogator, the state prosecutor, the prisoner and the judges present. In the American system, evidence derived under "torture" was admissible.

The Bush administration concluded that the Geneva Conventions did not apply to al-Qaeda detainees; similarly, the Soviets argued that international law did not apply to foreign detainees.

Communist-style interrogation routinely produced false confessions.

"The cumulative effects of the entire experience may be almost intolerable. [The prisoner] becomes mentally dull and loses his capacity for discrimination. He becomes malleable and suggestible, and in some instances he may confabulate (to fill gaps in one's memory with fabrications that one believes to be facts). By suggesting that the prisoner accept half-truths and plausivel distortions of the truth, [the interrogator] makes it possible for the prisoner to rationalize and thus accept the interrogator's viewpoint as the only way out of an intolerable situation." (1956 Report)

A more recent Times article, "Rights Group Offers Grim View of C.I.A. Jails" (6/9/07), gives a bleak description of life in the secret prisons run by the C.I.A. in Eastern Europe. This description was given in a report prepared by Dick Marty, a Swiss senator investigating C.I.A. operations for the Council of Europe, a 46-nation rights group. According to the report, prisoners guarded by silent men in black masks and dark visors were held naked in cramped cells and shackled to walls. Ventilation holes in the cells released bursts of hot or freezing air, with temperatures used as a form of extreme pressure to wear down the prisoners. Prisoners were also subjected to waterboarding and relentless blasts of music and sound, from rap to cackling laughter and screams.

The report relies heavily on testimony from C.I.A. agents.

A spokesman for the Polish Ministry of Foreign Affairs said, "There were no secret C.I.A. detention centers on the territory of the Republic of Poland." But Mr. Marty said at a news conference that the anonymous testimony of the agents was backed by thousands of flight records showing prisoner transfers, including private jets linked to the C.I.A., that made 10 flights from Afghanistan and Dubai to the Szczytno-Szymany International Airport in Poland between 2002 to 2005. That was the closest airport to a Soviet-era military compound. The C.I.A. jails were set off from the country in which they were located by a buffer zone. The jails were run exclusively by Americans.

The details of prison life were given by retired and current American intelligence agents who were promised confidentiality. As Mr. Marty said, "For 15 years I have interviewed people as an investigating magistrate and I have always noticed that at a certain point, people with secrets need to talk."

According to the report, suspects were often held for months with no contact to the outside world except with masked, silent guards who would push meals of cheese, potatoes and bread through hatches.

Friday, June 1, 2007

The Age of Unreason

Al Gore's book, "The Assault on Reason", is #1 on Amazon's list. Does this mean people are engaging in reason, logic, fact-checking? Unfortunately, as studies on advertising have shown, people are engaged on a more primitive, emotional level before their rational mind kicks in.

I haven't read the book, but I looked at the pictures (and read reviews, commentaries and saw him discuss the book on several shows, including Jon Stewart's). I believe his thesis is that the American people are being manipulated by cagy Machiavellians who use fear, pride and patriotism to infuse them with fact-free convictions
. To repeat what Dr. Joseph Goebbels said (someone who I'm sure Karl Rove takes to heart):

"If you tell a lie big enough and keep repeating it, people will eventually come
to believe it. The lie can be maintained only for such time as the State
can shield the people from the political, economic and/or military consequences
of the lie. It thus becomes vitally important for the State to use all of
its powers to repress dissent, for the truth is the mortal enemy of the lie, and
thus by extension, the truth is the greatest enemy of the state."

Bush & Company rely on stirring up our emotions, instilling fear, evoking pride and patriotism. Whenever Bush's poll numbers go down perilously, he mentions 9/11.

He was also recently "emboldened" (his favorite word for what people who disagree with him do to the enemy) by the Democrat's cave-in on the Iraq War supplemental funding bill. The Democrats completely neutered the bill they passed. There are no stipulations; neither the U.S. nor the Iraqi government are required to meet any benchmarks and even if there were benchmarks, there would be no penalty for not meeting them.

When the Democrats retreated from their strong initial stance, Bush crowed and preened himself as if he faced down Osama Bin Laden. He declassified and "leaked" intelligence that bin Laden was defeated somehow in 2005 (I'm not clear on the details; the gist was that the government had been doing something about someone who actually planned and executed 9/11.)

Another argument Gore makes is that Bush & Co. came in with predetermined goals, such as "let's invade Iraq" and "let's make the U.S. a wholly owned subsidiary of the Republican Party." In that case, there is no room for facts. As Goebbels said (see above), "(T)he truth is the mortal enemy of the lie, and thus by extension, the truth is the greatest enemy of the State." All inconvenient facts are made to conform to the ideology. The ends justify the means.

Another Guantanamo detainee killed himself yesterday. There were about 380 people kept there. Now there are about 379. Some of the detainees have been there for 5 years. They are told they will never be released. Most of these people have not been charged and the legal rules have changed to prevent them from ever challenging their situation. It's inevitable that there will be more suicides.

I saw the spokesman (don't remember his name) from on Countdown yesterday. He was sadly resigned. At Fort Lewis the decision was made not to hold individual funerals honoring one fallen soldier, but to hold one funeral a month to honor all the soldiers that died that month. The spokesman from Fort Lewis said it was done because "there were too many soldiers dying."

Meanwhile, Bush says we will stay there indefinitely (like in Korea). Only Iraq is not Korea. In Korea we had multi-national agreement. We have had relative peace for decades. Anyway, Bush's statement is a recruiting slogan for al Qaeda. I briefly glimpsed a picture of the new American Embassy in Iraq. It's huge (larger than 3 football fields) with all the amenities of home and then some.

Republican candidates fervently declare their support of torture as an interrogation technique despite all evidence that it doesn't produce valid intelligence. And Joe Lieberman goes to Iraq to declare that "progress is being made", resolutely refusing to hear the soldiers' cries, "When are we getting to go home? We're riding around waiting to be shot."

Somehow this is related: An article in the N.Y. Times yesterday described the plight of refugees seeking entry into the United States. Their fates vary widely depending on what immigration judge they draw. In some cases, with judges from the same court (for instance, Miami), one will allow 70% of the cases to remain in the U.S.; the other will allow 5%. There is no real rhyme or reason, no system or legal structure to guide these decisions.

At the end of the article, the reporter slipped in that Monica Goodling, the liaison between the DoJ and the White House, not only vetted potential DoJ prosecutors and civil servants, she also passed judgment on immigration judges.

Next entry: How is Bush & Co. like the Nazi regime? (I already gave you a clue with Goebbel's quote.)